Scaling TB Preventive Therapy (TPT) among people living with HIV in Ethiopia

Addis Ababa City Administration Health Bureau team discussing TPT coverage at Alert hospital Photo By: Florian Mutasingwa

About one-fourth of the world’s population is estimated to be infected with mycobacterium tuberculosis (TB), the organism that causes TB disease. Although it is curable and treatable, more than 10 million people develop active TB disease around the world each year. The risk of developing TB is higher for those with a compromised immune system, including people living with HIV (PLHIV), for whom the risk is 20 times higher compared to those without HIV. TB is one of the most common life-threatening opportunistic infections and a leading cause of death among PLHIV. Through support from the U.S. President’s Emergency Plan for AIDS Relief, U.S. Centers for Disease Control and Prevention (CDC) is on the front lines to bring an end to these dual epidemics.

For PLHIV, effective screening and tuberculosis preventive treatment (TPT) can prevent TB infection. TPT is a proven course of treatment that can prevent TB disease among those infected with TB, and has been shown to reduce TB-related mortality among people living with HIV by 37 percent. Coupled with antiretroviral therapy, TPT can lower the risk of TB disease and help PLHIV live longer healthier lives.

Leveraging partnerships for equitable access to TPT

Many in the populations most vulnerable to TB, including children, people living with HIV, and healthcare workers, lack support for the TB treatment they need. Stigma, discrimination, and other barriers exist that prevent access to TPT. Improving TPT utilization requires close investigation of these factors and innovative solutions to overcome these barriers. CDC Ethiopia partnered with Regional Health Bureaus (RHBs) to identify 15 health facilities with a PLHIV client load of more than 1,000 but less than 70% TPT coverage.

These facilities received intensified site-level support and mentorship by respective regional health bureau partners, which was often required a shift to virtual interactions due to the COVID-19 pandemic. CDC Ethiopia also provided six months’ support (April-September 2021) to help implement quality improvement approaches to improve TPT uptake and completion among those served at the health facilities.

Increasing mentorship to sustain impact

RHB implementing partners managed the overall targeted TPT intervention in their respective regions. RHB focal persons also conducted regular performance monitoring with CDC and CDC implementation partner, ICAP to ensure the greatest impact was achieved. In April 2021, only 60% of PLHIV received TPT at the 15 sites. By the end of the initiative, in September 2021, PLHIV receiving TPT increased to 74%. Within six months, CDC Ethiopia’s innovative program provided lifesaving TPT to an additional 7,931 PLHIV who were on antiretroviral therapy.

Several features of CDC Ethiopia’s support were effective in improving program performance. These include:

  • Prioritizing high client load facilities with low TPT coverage performance as a cost-effective approach helped achieve maximum impact with minimal investment. This was accomplished by addressing the massive backlog of TPT coverage at these few facilities.
  • Monthly virtual progress meetings organized by CDC’s Division of Global HIV and TB were instrumental in identifying program successes and challenges. During the calls, CDC also provided technical assistance, shared best practices amongst health facilities, and identified challenges for performance improvement planning.
  • Electronic medical record data was instrumental for close monitoring of program progress in near real-time and providing timely support for course corrections.

CDC and partners intend to expand these cost-effective interventions to additional health facilities and prioritizing facilities with significant TPT coverage gaps to achieve greater program impact. “TB is a major killer of PLHIV, and TPT is the most effective tool we have to protect these individuals from active TB. CDC has supported the Ministry of Health, Regional Health Bureaus, health facilities, and other stakeholders in Ethiopia to prioritize increased TPT uptake and completion,” shared Dr. Caroline Ryan, CDC Ethiopia country director. “Our experience shows that cost-effective intensified support and targeted site selection can rapidly expand TPT coverage and reduce TB-related deaths, a strategy that works in Ethiopia and potentially in other countries,” Dr. Ryan added.

Intensified TPT support in Ethiopia